Healthcare Provider Details

I. General information

NPI: 1295235984
Provider Name (Legal Business Name): JON ALVIN RIEGO DE DIOS MODESTO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

746 AVENUE D
DANVILLE PA
17821-7635
US

IV. Provider business mailing address

746 AVENUE D
DANVILLE PA
17821-7635
US

V. Phone/Fax

Practice location:
  • Phone: 928-209-4048
  • Fax:
Mailing address:
  • Phone: 928-209-4048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP036426
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95118046
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-85497
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2320628
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number884244
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN205182
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN712916
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: